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JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY December 2017 • Volume 10 • Number 12
O R I G I N A L R E S E A R C H
studies investigating factors associated
with poor patient adherence to melanoma
surveillance.
15–17
However, recent evidence
suggests that reduced frequency of follow-up
visits in early-stage melanoma patients does
not negatively affect recurrence, patients'
psychological well-being, or detection of
subsequent primary melanoma.
18,19
With the
ultimate goal of identifying patients who
might benefit from additional counseling
on the importance of melanoma follow-up,
we investigate factors associated with poor
melanoma surveillance adherence using two
follow-up schedules derived from the NCCN
guidelines.
METHODS
A retrospective chart review was performed
on patient records with diagnosis codes of
melanoma of the skin (ICD-9 172.9) and
personal history of melanoma (ICD-9 V10.82)
between January 2005 and November 2015.
Patients without an available pathology report
on file to confirm a melanoma diagnosis
were excluded. All study procedures were
performed after obtaining approval by the
institutional review board of Loyola University
Chicago's Health Sciences Division. For
patients diagnosed with melanoma within
the Loyola University Health System (LUHS),
dermatology clinic visits were reviewed for
a span of five years starting from the date of
initial diagnosis of melanoma. For patients
with a known personal history of melanoma
diagnosed outside of the LUHS, dermatology
clinic visits were reviewed for a span of five
years from initial contact with the LUHS. Only
dermatology encounters were included in
recording follow-up visits. Patients who failed
to follow up with dermatology, but were seen
in surveillance by oncology or other specialties,
were excluded for the purposes of this study.
Basic demographic data , including age, sex,
race, marital status, proximity of residence
to clinic, median household income (as
determined by ZIP code), and health insurance
status were obtained. Data on selected risk
factors for melanoma were also abstracted
from patients' electronic medical records, when
available, including history of non-melanoma
skin cancer, tanning bed use, and history of
blistering sunburns. Each patient's clinical
stage for melanoma was recorded based on
available pathology reports, including data
from wide local excision, sentinel lymph node
biopsy, and completion lymphadenectomy.
Criteria for aggressive and conservative
surveillance adherence. The "aggressive"
surveillance schedule was defined as follows:
Stage 0 (melanoma in situ): at least one visit
each year for five years; Stages IA to IIA: at
least two visits each year for five years; Stages
IIB to IV: at least four visits for Year 1, at least
three visits for Year 2, and at least two visits
for Years 3 to 5. The "conservative" surveillance
adherence schedule was defined as follows:
Stages 0 to IIA: at least one visit each year for
five years; Stages IIB to IV: at least two visits
in each of the first two years and at least one
visit in the next three years. Patient adherence
trends were divided into three groups (Table
1) in decreasing order of adherence: "adherent
to aggressive surveillance" if they adhered to
the "aggressive" surveillance schedule; "poorly
adherent to aggressive surveillance" if they
adhered to the "conservative" schedule but
did not adhere to the "aggressive" adherence
schedule; or "poorly adherent to conservative
schedule" if they were not adherent to either
schedule. Surveillance adherence was not
calculated before patients first visited the
LUHS, or after they left for another practice.
Statistical analysis. Patient characteristics
and annual adherence were presented as
counts and percentages. The associations
between patient characteristics and adherence
were assessed in separate univariable
proportional odds mixed models predicting
poorer levels of adherence. A multivariable
proportional odds regression mixed model
included variables with p<0.25 in univariable
analysis. The mixed models included random
intercepts to account for within-patient
correlation over up to five years of follow-up.
RESULTS
Patient characteristics. Of 186 patients
included, the average age was 55 (standard
deviation [SD]=15) years old, 45.7 percent
(n=85) were female, 94.1 percent (n=175)
were white, and 75.8 percent (n=141) were
married. The majority of patients lived farther
than 10 miles from the clinic (111/184, 60.3%)
and had private insurance (n=109, 58.6%).
Nearly all patients had between Stages 0 to
IIA disease (n=169, 90.9%). A minority of
patients had a history of tanning bed use
(13.8%), blistering sunburns (20.4%), or
non-melanoma skin cancer (21.0%). ZIP code-
based household income varied, with 19.4
percent of patients living in ZIP codes with
a median income of less than $60,000, 30.1
percent with $60,000 to $74,000, 24.7 percent
with $75,000 to $90,000, and 25.8 percent
with over $90,000 (Table 2).
Surveillance adherence rates.
Between 58.4 and 74.5 percent of patients
TABLE 1. Surveillance adherence groups
YEAR
ADHERENT TO AGGRESSIVE SURVEILLANCE
POORLY ADHERENT TO AGGRESSIVE
SURVEILLANCE
POORLY ADHERENT TO CONSERVATIVE SURVEILLANCE
MIS IA-IIA IIB-IV MIS-IIA IIB-IV MIS-IIA IIB-IV
1 ≥1 visit per year ≥2 visits per year ≥4 visits per year ≥1 visit per year ≥2 visits per year <1 visit per year <2 visits per year
2 ≥1 visit per year ≥2 visits per year ≥4 visits per year ≥1 visit per year ≥2 visits per year <1 visit per year <2 visits per year
3 ≥1 visit per year ≥2 visits per year ≥3 visits per year ≥1 visit per year ≥1 visit per year <1 visit per year <1 visit per year
4 ≥1 visit per year ≥2 visits per year ≥3 visits per year ≥1 visit per year ≥1 visit per year <1 visit per year <1 visit per year
5 ≥1 visit per year ≥2 visits per year ≥3 visits per year ≥1 visit per year ≥1 visit per year <1 visit per year <1 visit per year
MIS: melanoma in situ (stage 0)